Provider Demographics
NPI:1174546337
Name:HOLMBERG, TRENT C (MD)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:C
Last Name:HOLMBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12481 S FORT ST STE 275
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-2106
Mailing Address - Country:US
Mailing Address - Phone:801-432-2077
Mailing Address - Fax:801-432-2079
Practice Address - Street 1:12481 S FORT ST STE 275
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-2106
Practice Address - Country:US
Practice Address - Phone:801-432-2077
Practice Address - Fax:801-432-2079
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT376105-12052084P0800X
UT37610512052084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005767401Medicare PIN
UT006900209Medicare PIN